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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,•OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 - zGJ <br /> C, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 <br /> ' r (Complete In Triplicate) <br /> Application s hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT -- <br /> Owner's Name �/ L Phone �G 9YS" <br /> Address c,--42 City <br /> Contractor's Name j�,Q/�L ,� � p /7_.,> /.[/„/ � .,License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN' / / RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 0— SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /moo / CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLZ22 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial )(�Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /tJ <br /> / <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - T <br /> Cathodic..Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical - Surface Seal Installed By: 44 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well-Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the. SAn Joaquin Local Health District <br /> and the. State. of California pertaining to or regulating well '-construction. Within FIFTEEN DA '�S <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT. INSPECTION <br /> PRIOR TO GRO IN D A FINAL INSPECTI <br /> SIGNED TITLE <br /> (DlbkW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE -26 - 7 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 2M t <br />